Workers' Comp Treatment Denied in California — UR, IMR, and the 30-Day Appeal Clock

Why did the insurance company deny my treatment?

Most denials come from Utilization Review. A reviewer checks your doctor's request against state medical guidelines. Care outside those rules often gets denied.

Your treating doctor sends a Request for Authorization. People call it an RFA. The insurer then runs Utilization Review, or UR. Under Labor Code 4610, UR checks your request against state medical rules. A reviewing doctor, not your adjuster, makes the call.

Those rules are the MTUS. That means the Medical Treatment Utilization Schedule. A UR doctor has a few choices. They can approve the care. They can deny it. Or they can modify it. Modify means they cut it down. They might cut your therapy visits in half.

Denials usually come down to a few reasons. The request may fall outside the MTUS. The records may be too thin. The reviewer may call the care "not medically necessary." Sometimes the request is just missing key facts. The good news is that each of these can be fixed. A clearer request often turns a no into a yes.

This stings. Your care should be free. Labor Code 4600 covers all needed treatment. You pay nothing out of pocket. There is no copay. A denial does not erase that right. It just means you have to fight for it.

How do I appeal a denied treatment request?

You appeal through Independent Medical Review, called IMR. You must file within 30 days of the denial. A new doctor then reviews your case.

When UR denies care, you get to appeal. The appeal is called Independent Medical Review, or IMR. Labor Code 4610.5 sets up this right. A doctor with no tie to your case looks at the denial. They check it against the same MTUS rules.

The clock is short. You have 30 days from the date on the denial. The IMR form comes inside your denial letter. Sign it and send it back fast. Miss the deadline and the denial usually sticks. So do not sit on that letter.

IMR is a paper review. The new doctor does not examine you. They read the records instead. So strong records matter. You can send in more medical proof to support your case. Watch these key deadlines:

That last row surprises many workers. Even before your claim is accepted, you are owed care. Labor Code 5402(c) gives you up to $10,000 in treatment during the review. After you file IMR, a new doctor reviews everything and sends a written decision. Keep every letter you get. Those records help your lawyer later.

How can my doctor write a stronger treatment request?

Your doctor should match the request to the MTUS guidelines. The strongest requests cite your exam findings, the failed care, and the medical reason.

UR often denies care when the request is thin. A few lines will not do the job. Your doctor must show why the care is truly needed.

A strong RFA does a few things. It links your symptoms to the exam. It lists the treatments you already tried. It explains how the next step fits the MTUS. It points to the exact guideline that supports the care. Clear, detailed records win appeals.

Your doctor can also ask for a peer review. That is a direct talk with the UR doctor. A quick call can clear up a thin file. It can save weeks of waiting. Not every doctor offers this, so it helps to ask.

A fresh opinion can help too. You can see another doctor inside the network. A new exam can turn up new findings. Those findings can support a new request. More proof gives UR less room to say no. Old records help too. A past MRI or x-ray can back up the request. Hand your doctor everything you have.

What if IMR still says no?

You still have options. Your doctor can send a new request with better proof. A lawyer can also challenge how the review was run.

An IMR denial hurts. It is not always the final word, though. You did nothing wrong by asking for care. Your health can also change over time. A new problem or a new exam finding can support a fresh request. Your doctor can send a new RFA when that happens.

You can also question the process itself. Sometimes UR misses its own deadline. Sometimes the reviewer ignores key records. Sometimes there is a clear mistake of fact. These errors can be challenged. A late UR decision may even mean the care must be approved.

Do not stop your other care while you appeal. Keep your approved treatment going. Keep every appointment. Keep telling your doctor how you feel. A steady record helps your appeal more than a gap ever could.

This is hard to do alone. A workers' comp lawyer knows where to look. They can read the fine print and spot the mistakes. You should not have to study the law while you are hurt. Let someone fight this part for you.